Provider Demographics
NPI:1598828477
Name:MOBILE DENTAL SERVICES, LLC
Entity Type:Organization
Organization Name:MOBILE DENTAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:918-706-5584
Mailing Address - Street 1:615 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:STROUD
Mailing Address - State:OK
Mailing Address - Zip Code:74079-5316
Mailing Address - Country:US
Mailing Address - Phone:918-706-5584
Mailing Address - Fax:
Practice Address - Street 1:615 E 17TH ST
Practice Address - Street 2:
Practice Address - City:STROUD
Practice Address - State:OK
Practice Address - Zip Code:74079-5316
Practice Address - Country:US
Practice Address - Phone:918-706-5584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK58091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty